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Textbook of medical physiology
Arthur C. Guyton, John E. Hall
2006
1115
60MB
PDF
2900 تومان0000



Introduction to Physiology: The
Cell and General Physiology
C H A P T E R 1
Functional Organization of the
Human Body and Control of the
“Internal Environment” 3
Cells as the Living Units of the Body 3
Extracellular Fluid—The “Internal
Environment” 3
“Homeostatic” Mechanisms of the Major
Functional Systems 4
Homeostasis 4
Extracellular Fluid Transport and Mixing
System—The Blood Circulatory System 4
Origin of Nutrients in the Extracellular Fluid 5
Removal of Metabolic End Products 5
Regulation of Body Functions 5
Reproduction 6
Control Systems of the Body 6
Examples of Control Mechanisms 6
Characteristics of Control Systems 7
Summary—Automaticity of the Body 9
C H A P T E R 2
The Cell and Its Functions 11
Organization of the Cell 11
Physical Structure of the Cell 12
Membranous Structures of the Cell 12
Cytoplasm and Its Organelles 14
Nucleus 17
Nuclear Membrane 17
Nucleoli and Formation of Ribosomes 18
Comparison of the Animal Cell with
Precellular Forms of Life 18
Functional Systems of the Cell 19
Ingestion by the Cell—Endocytosis 19
Digestion of Pinocytotic and Phagocytic
Foreign Substances Inside the Cell—
Function of the Lysosomes 20
Synthesis and Formation of Cellular
Structures by Endoplasmic Reticulum
and Golgi Apparatus 20
Extraction of Energy from Nutrients—
Function of the Mitochondria 22
Locomotion of Cells 24
Ameboid Movement 24
Cilia and Ciliary Movement 24
C H A P T E R 3
Genetic Control of Protein Synthesis,
Cell Function, and Cell Reproduction 27
Genes in the Cell Nucleus 27
Genetic Code 29
xiii
The DNA Code in the Cell Nucleus Is
Transferred to an RNA Code in the
Cell Cytoplasm—The Process
of Transcription 30
Synthesis of RNA 30
Assembly of the RNA Chain from Activated
Nucleotides Using the DNA Strand
as a Template—The Process of
“Transcription” 31
Messenger RNA—The Codons 31
Transfer RNA—The Anticodons 32
Ribosomal RNA 33
Formation of Proteins on the Ribosomes—
The Process of “Translation” 33
Synthesis of Other Substances in the
Cell 35
Control of Gene Function and
Biochemical Activity in Cells 35
Genetic Regulation 35
Control of Intracellular Function by
Enzyme Regulation 36
The DNA-Genetic System Also Controls
Cell Reproduction 37
Cell Reproduction Begins with Replication
of DNA 37
Chromosomes and Their Replication 38
Cell Mitosis 38
Control of Cell Growth and Cell
Reproduction 39
Cell Differentiation 40
Apoptosis—Programmed Cell Death 40
Cancer 40
U N I T I I
Membrane Physiology, Nerve,
and Muscle
C H A P T E R 4
Transport of Substances Through
the Cell Membrane 45
The Lipid Barrier of the Cell Membrane,
and Cell Membrane Transport
Proteins 45
Diffusion 46
Diffusion Through the Cell Membrane 46
Diffusion Through Protein Channels, and
“Gating” of These Channels 47
Facilitated Diffusion 49
Factors That Affect Net Rate of Diffusion 50
Osmosis Across Selectively Permeable
Membranes—“Net Diffusion” of Water 51
“Active Transport” of Substances
Through Membranes 52
Primary Active Transport 53
Secondary Active Transport—Co-Transport
and Counter-Transport 54
Active Transport Through Cellular Sheets 55
C H A P T E R 1 8
Nervous Regulation of the Circulation,
and Rapid Control of Arterial Pressure 204
Nervous Regulation of the Circulation 204
Autonomic Nervous System 204
Role of the Nervous System in Rapid
Control of Arterial Pressure 208
Increase in Arterial Pressure During Muscle
Exercise and Other Types of Stress 208
Reflex Mechanisms for Maintaining Normal
Arterial Pressure 209
Central Nervous System Ischemic
Response—Control of Arterial Pressure
by the Brain’s Vasomotor Center in
Response to Diminished Brain Blood
Flow 212
Special Features of Nervous Control
of Arterial Pressure 213
Role of the Skeletal Nerves and Skeletal
Muscles in Increasing Cardiac Output
and Arterial Pressure 213
Respiratory Waves in the Arterial Pressure 214
Arterial Pressure “Vasomotor” Waves—
Oscillation of Pressure Reflex Control
Systems 214
C H A P T E R 1 9
Dominant Role of the Kidney in Long-
Term Regulation of Arterial Pressure
and in Hypertension: The Integrated
System for Pressure Control 216
Renal–Body Fluid System for Arterial
Pressure Control 216
Quantitation of Pressure Diuresis as a Basis
for Arterial Pressure Control 217
Chronic Hypertension (High Blood Pressure)
Is Caused by Impaired Renal Fluid
Excretion 220
The Renin-Angiotensin System:
Its Role in Pressure Control and in
Hypertension 223
Components of the Renin-Angiotensin
System 223
Types of Hypertension in Which Angiotensin
Is Involved: Hypertension Caused by a
Renin-Secreting Tumor or by Infusion
of Angiotensin II 226
Other Types of Hypertension Caused by
Combinations of Volume Loading and
Vasoconstriction 227
“Primary (Essential) Hypertension” 228
Summary of the Integrated,
Multifaceted System for Arterial
Pressure Regulation 230
C H A P T E R 2 0
Cardiac Output, Venous Return,
and Their Regulation 232
Normal Values for Cardiac Output at
Rest and During Activity 232
Control of Cardiac Output by Venous
Return—Role of the Frank-Starling
Mechanism of the Heart 232
Cardiac Output Regulation Is the Sum of
Blood Flow Regulation in All the Local
Tissues of the Body—Tissue Metabolism
Regulates Most Local Blood Flow 233
The Heart Has Limits for the Cardiac Output
That It Can Achieve 234
What Is the Role of the Nervous System in
Controlling Cardiac Output? 235
Pathologically High and Pathologically
Low Cardiac Outputs 236
High Cardiac Output Caused by Reduced
Total Peripheral Resistance 236
Low Cardiac Output 237
A More Quantitative Analysis of Cardiac
Output Regulation 237
Cardiac Output Curves Used in the
Quantitative Analysis 237
Venous Return Curves 238
Analysis of Cardiac Output and Right Atrial
Pressure, Using Simultaneous Cardiac
Output and Venous Return Curves 241
Methods for Measuring Cardiac
Output 243
Pulsatile Output of the Heart as Measured
by an Electromagnetic or Ultrasonic
Flowmeter 243
Measurement of Cardiac Output Using the
Oxygen Fick Principle 244
Indicator Dilution Method for Measuring
Cardiac Output 244
C H A P T E R 2 1
Muscle Blood Flow and Cardiac
Output During Exercise; the
Coronary Circulation and Ischemic
Heart Disease 246
Blood Flow in Skeletal Muscle
and Blood Flow Regulation
During Exercise 246
Rate of Blood Flow Through the Muscles 246
Control of Blood Flow Through the Skeletal
Muscles 247
Total Body Circulatory Readjustments
During Exercise 247
Coronary Circulation 249
Physiologic Anatomy of the Coronary Blood
Supply 249
Normal Coronary Blood Flow 249
Control of Coronary Blood Flow 250
Special Features of Cardiac Muscle
Metabolism 251
Ischemic Heart Disease 252
Causes of Death After Acute Coronary
Occlusion 253
Stages of Recovery from Acute
Myocardial Infarction 254
Function of the Heart After Recovery
from Myocardial Infarction 255
Pain in Coronary Heart Disease 255
Surgical Treatment of Coronary Disease 256
C H A P T E R 2 2
Cardiac Failure 258
Dynamics of the Circulation in
Cardiac Failure 258
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Acute Effects of Moderate Cardiac Failure 258
Chronic Stage of Failure—Fluid Retention
Helps to Compensate Cardiac Output 259
Summary of the Changes That Occur After
Acute Cardiac Failure—“Compensated
Heart Failure” 260
Dynamics of Severe Cardiac Failure—
Decompensated Heart Failure 260
Unilateral Left Heart Failure 262
Low-Output Cardiac Failure—
Cardiogenic Shock 262
Edema in Patients with Cardiac Failure 263
Cardiac Reserve 264
Quantitative Graphical Method for Analysis
of Cardiac Failure 265
C H A P T E R 2 3
Heart Valves and Heart Sounds;
Dynamics of Valvular and Congenital
Heart Defects 269
Heart Sounds 269
Normal Heart Sounds 269
Valvular Lesions 271
Abnormal Circulatory Dynamics in
Valvular Heart Disease 272
Dynamics of the Circulation in Aortic
Stenosis and Aortic Regurgitation 272
Dynamics of Mitral Stenosis and Mitral
Regurgitation 273
Circulatory Dynamics During Exercise in
Patients with Valvular Lesions 273
Abnormal Circulatory Dynamics in
Congenital Heart Defects 274
Patent Ductus Arteriosus—A Left-to-Right
Shunt 274
Tetralogy of Fallot—A Right-to-Left Shunt 274
Causes of Congenital Anomalies 276
Use of Extracorporeal Circulation
During Cardiac Surgery 276
Hypertrophy of the Heart in Valvular
and Congenital Heart Disease 276
C H A P T E R 2 4
Circulatory Shock and Physiology of
Its Treatment 278
Physiologic Causes of Shock 278
Circulatory Shock Caused by Decreased
Cardiac Output 278
Circulatory Shock That Occurs Without
Diminished Cardiac Output 278
What Happens to the Arterial Pressure in
Circulatory Shock? 279
Tissue Deterioration Is the End Result of
Circulatory Shock, Whatever the Cause 279
Stages of Shock 279
Shock Caused by Hypovolemia—
Hemorrhagic Shock 279
Relationship of Bleeding Volume to
Cardiac Output and Arterial Pressure 279
Progressive and Nonprogressive
Hemorrhagic Shock 280
Irreversible Shock 284
Hypovolemic Shock Caused by Plasma
Loss 284
Hypovolemic Shock Caused by Trauma 285
Neurogenic Shock—Increased Vascular
Capacity 285
Anaphylactic Shock and Histamine
Shock 285
Septic Shock 286
Physiology of Treatment in Shock 286
Replacement Therapy 286
Treatment of Shock with Sympathomimetic
Drugs—Sometimes Useful, Sometimes
Not 287
Other Therapy 287
Circulatory Arrest 287
Effect of Circulatory Arrest on the Brain 287
U N I T V
The Body Fluids and Kidneys
C H A P T E R 2 5
The Body Fluid Compartments:
Extracellular and Intracellular Fluids;
Interstitial Fluid and Edema 291
Fluid Intake and Output Are Balanced
During Steady-State Conditions 291
Daily Intake of Water 291
Daily Loss of Body Water 291
Body Fluid Compartments 292
Intracellular Fluid Compartment 293
Extracellular Fluid Compartment 293
Blood Volume 293
Constituents of Extracellular and
Intracellular Fluids 293
Ionic Composition of Plasma and
Interstitial Fluid Is Similar 293
Important Constituents of the Intracellular
Fluid 295
Measurement of Fluid Volumes in the
Different Body Fluid Compartments—
The Indicator-Dilution Principle 295
Determination of Volumes of Specific
Body Fluid Compartments 295
Regulation of Fluid Exchange and
Osmotic Equilibrium Between
Intracellular and Extracellular Fluid 296
Basic Principles of Osmosis and
Osmotic Pressure 296
Osmotic Equilibrium Is Maintained
Between Intracellular and
Extracellular Fluids 298
Volume and Osmolality of Extracellular
and Intracellular Fluids in Abnormal
States 299
Effect of Adding Saline Solution to the
Extracellular Fluid 299
Glucose and Other Solutions
Administered for Nutritive Purposes 301
Clinical Abnormalities of Fluid Volume
Regulation: Hyponatremia and
Hypernatremia 301
Causes of Hyponatremia: Excess Water or
Loss of Sodium 301
Causes of Hypernatremia: Water Loss or
Excess Sodium 302
Edema: Excess Fluid in the Tissues 302
Intracellular Edema 302
Extracellular Edema 302
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Summary of Causes of Extracellular Edema 303
Safety Factors That Normally Prevent
Edema 304
Fluids in the “Potential Spaces” of
the Body 305
C H A P T E R 2 6
Urine Formation by the Kidneys:
I. Glomerular Filtration, Renal Blood
Flow, and Their Control 307
Multiple Functions of the Kidneys in
Homeostasis 307
Physiologic Anatomy of the Kidneys 308
General Organization of the Kidneys and
Urinary Tract 308
Renal Blood Supply 309
The Nephron Is the Functional Unit of the
Kidney 310
Micturition 311
Physiologic Anatomy and Nervous
Connections of the Bladder 311
Transport of Urine from the Kidney
Through the Ureters and into
the Bladder 312
Innervation of the Bladder 312
Filling of the Bladder and Bladder Wall
Tone; the Cystometrogram 312
Micturition Reflex 313
Facilitation or Inhibition of Micturition
by the Brain 313
Abnormalities of Micturition 313
Urine Formation Results from
Glomerular Filtration, Tubular
Reabsorption, and Tubular Secretion 314
Filtration, Reabsorption, and Secretion of
Different Substances 315
Glomerular Filtration—The First Step in
Urine Formation 316
Composition of the Glomerular Filtrate 316
GFR Is About 20 Per Cent of the Renal
Plasma Flow 316
Glomerular Capillary Membrane 316
Determinants of the GFR 317
Increased Glomerular Capillary Filtration
Coefficient Increases GFR 318
Increased Bowman’s Capsule Hydrostatic
Pressure Decreases GFR 318
Increased Glomerular Capillary Colloid
Osmotic Pressure Decreases GFR 318
Increased Glomerular Capillary Hydrostatic
Pressure Increases GFR 319
Renal Blood Flow 320
Renal Blood Flow and Oxygen
Consumption 320
Determinants of Renal Blood Flow 320
Blood Flow in the Vasa Recta of the Renal
Medulla Is Very Low Compared with Flow
in the Renal Cortex 321
Physiologic Control of Glomerular
Filtration and Renal Blood Flow 321
Sympathetic Nervous System Activation
Decreases GFR 321
Hormonal and Autacoid Control of Renal
Circulation 322
Autoregulation of GFR and Renal
Blood Flow 323
Importance of GFR Autoregulation in
Preventing Extreme Changes in Renal
Excretion 323
Role of Tubuloglomerular Feedback in
Autoregulation of GFR 323
Myogenic Autoregulation of Renal Blood
Flow and GFR 325
Other Factors That Increase Renal Blood
Flow and GFR: High Protein Intake and
Increased Blood Glucose 325
C H A P T E R 2 7
Urine Formation by the Kidneys:
II. Tubular Processing of the
Glomerular Filtrate 327
Reabsorption and Secretion by the
Renal Tubules 327
Tubular Reabsorption Is Selective and
Quantitatively Large 327
Tubular Reabsorption Includes
Passive and Active Mechanisms 328
Active Transport 328
Passive Water Reabsorption by Osmosis
Is Coupled Mainly to Sodium
Reabsorption 332
Reabsorption of Chloride, Urea, and Other
Solutes by Passive Diffusion 332
Reabsorption and Secretion Along
Different Parts of the Nephron 333
Proximal Tubular Reabsorption 333
Solute and Water Transport in the Loop
of Henle 334
Distal Tubule 336
Late Distal Tubule and Cortical Collecting
Tubule 336
Medullary Collecting Duct 337
Summary of Concentrations of Different
Solutes in the Different Tubular
Segments 338
Regulation of Tubular Reabsorption 339
Glomerulotubular Balance—The Ability
of the Tubules to Increase Reabsorption
Rate in Response to Increased Tubular
Load 339
Peritubular Capillary and Renal Interstitial
Fluid Physical Forces 339
Effect of Arterial Pressure on Urine
Output—The Pressure-Natriuresis and
Pressure-Diuresis Mechanisms 341
Hormonal Control of Tubular Reabsorption 342
Sympathetic Nervous System Activation
Increases Sodium Reabsorption 343
Use of Clearance Methods to Quantify
Kidney Function 343
Inulin Clearance Can Be Used to Estimate
GFR 344
Creatine Clearance and Plasma Creatinine
Clearance Can Be Used to Estimate
GFR 344
PAH Clearance Can Be Used to Estimate
Renal Plasma Flow 345
Filtration Fraction Is Calculated from GFR
Divided by Renal Plasma Flow 346
Calculation of Tubular Reabsorption or
Secretion from Renal Clearance 346
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C H A P T E R 2 8
Regulation of Extracellular Fluid
Osmolarity and Sodium
Concentration 348
The Kidneys Excrete Excess Water
by Forming a Dilute Urine 348
Antidiuretic Hormone Controls Urine
Concentration 348
Renal Mechanisms for Excreting a
Dilute Urine 349
The Kidneys Conserve Water by
Excreting a Concentrated Urine 350
Obligatory Urine Volume 350
Requirements for Excreting a Concentrated
Urine—High ADH Levels and Hyperosmotic
Renal Medulla 350
Countercurrent Mechanism Produces a
Hyperosmotic Renal Medullary Interstitium 351
Role of Distal Tubule and Collecting Ducts in
Excreting a Concentrated Urine 352
Urea Contributes to Hyperosmotic Renal
Medullary Interstitium and to a
Concentrated Urine 353
Countercurrent Exchange in the Vasa Recta
Preserves Hyperosmolarity of the
Renal Medulla 354
Summary of Urine Concentrating Mechanism
and Changes in Osmolarity in Different
Segments of the Tubules 355
Quantifying Renal Urine Concentration
and Dilution: “Free Water” and Osmolar
Clearances 357
Disorders of Urinary Concentrating
Ability 357
Control of Extracellular Fluid Osmolarity
and Sodium Concentration 358
Estimating Plasma Osmolarity from Plasma
Sodium Concentration 358
Osmoreceptor-ADH Feedback System 358
ADH Synthesis in Supraoptic and
Paraventricular Nuclei of the
Hypothalamus and ADH Release from
the Posterior Pituitary 359
Cardiovascular Reflex Stimulation of ADH
Release by Decreased Arterial Pressure
and/or Decreased Blood Volume 360
Quantitative Importance of Cardiovascular
Reflexes and Osmolarity in Stimulating
ADH Secretion 360
Other Stimuli for ADH Secretion 360
Role of Thirst in Controlling Extracellular
Fluid Osmolarity and Sodium
Concentration 361
Central Nervous System Centers for Thirst 361
Stimuli for Thirst 361
Threshold for Osmolar Stimulus of Drinking 362
Integrated Responses of Osmoreceptor-ADH
and Thirst Mechanisms in Controlling
Extracellular Fluid Osmolarity and Sodium
Concentration 362
Role of Angiotensin II and Aldosterone
in Controlling Extracellular Fluid
Osmolarity and Sodium Concentration 362
Salt-Appetite Mechanism for
Controlling Extracellular Fluid
Sodium Concentration and Volume 363
C H A P T E R 2 9
Renal Regulation of Potassium,
Calcium, Phosphate, and Magnesium;
Integration of Renal Mechanisms for
Control of Blood Volume and
Extracellular Fluid Volume 365
Regulation of Potassium Excretion
and Potassium Concentration in
Extracellular Fluid 365
Regulation of Internal Potassium
Distribution 366
Overview of Renal Potassium Excretion 367
Potassium Secretion by Principal Cells of
Late Distal and Cortical Collecting
Tubules 367
Summary of Factors That Regulate
Potassium Secretion: Plasma Potassium
Concentration, Aldosterone, Tubular Flow
Rate, and Hydrogen Ion Concentration 368
Control of Renal Calcium Excretion
and Extracellular Calcium Ion
Concentration 371
Control of Calcium Excretion by the
Kidneys 372
Regulation of Renal Phosphate Excretion 372
Control of Renal Magnesium Excretion
and Extracellular Magnesium Ion
Concentration 373
Integration of Renal Mechanisms for
Control of Extracellular Fluid 373
Sodium Excretion Is Precisely Matched to
Intake Under Steady-State Conditions 373
Sodium Excretion Is Controlled by Altering
Glomerular Filtration or Tubular Sodium
Reabsorption Rates 374
Importance of Pressure Natriuresis and
Pressure Diuresis in Maintaining Body
Sodium and Fluid Balance 374
Pressure Natriuresis and Diuresis Are Key
Components of a Renal-Body Fluid
Feedback for Regulating Body Fluid
Volumes and Arterial Pressure 375
Precision of Blood Volume and Extracellular
Fluid Volume Regulation 376
Distribution of Extracellular Fluid
Between the Interstitial Spaces and
Vascular System 376
Nervous and Hormonal Factors Increase
the Effectiveness of Renal-Body Fluid
Feedback Control 377
Sympathetic Nervous System Control of
Renal Excretion: Arterial Baroreceptor and
Low-Pressure Stretch Receptor Reflexes 377
Role of Angiotensin II In Controlling Renal
Excretion 377
Role of Aldosterone in Controlling Renal
Excretion 378
Role of ADH in Controlling Renal Water
Excretion 379
Role of Atrial Natriuretic Peptide in
Controlling Renal Excretion 378
Integrated Responses to Changes in
Sodium Intake 380
Conditions That Cause Large Increases
in Blood Volume and Extracellular
Fluid Volume 380
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Increased Blood Volume and Extracellular
Fluid Volume Caused by Heart Diseases 380
Increased Blood Volume Caused by
Increased Capacity of Circulation 380
Conditions That Cause Large Increases
in Extracellular Fluid Volume but with
Normal Blood Volume 381
Nephrotic Syndrome—Loss of Plasma
Proteins in Urine and Sodium Retention
by the Kidneys 381
Liver Cirrhosis—Decreased Synthesis of
Plasma Proteins by the Liver and
Sodium Retention by the Kidneys 381
C H A P T E R 3 0
Regulation of Acid-Base Balance 383
Hydrogen Ion Concentration Is
Precisely Regulated 383
Acids and Bases—Their Definitions
and Meanings 383
Defenses Against Changes in Hydrogen
Ion Concentration: Buffers, Lungs,
and Kidneys 384
Buffering of Hydrogen Ions in the Body
Fluids 385
Bicarbonate Buffer System 385
Quantitative Dynamics of the Bicarbonate
Buffer System 385
Phosphate Buffer System 387
Proteins: Important Intracellular
Buffers 387
Respiratory Regulation of Acid-Base
Balance 388
Pulmonary Expiration of CO2 Balances
Metabolic Formation of CO2 388
Increasing Alveolar Ventilation Decreases
Extracellular Fluid Hydrogen Ion
Concentration and Raises pH 388
Increased Hydrogen Ion Concentration
Stimulates Alveolar Ventilation 389
Renal Control of Acid-Base Balance 390
Secretion of Hydrogen Ions and
Reabsorption of Bicarbonate Ions
by the Renal Tubules 390
Hydrogen Ions Are Secreted by Secondary
Active Transport in the Early Tubular
Segments 391
Filtered Bicarbonate Ions Are Reabsorbed
by Interaction with Hydrogen Ions in the
Tubules 391
Primary Active Secretion of Hydrogen Ions in
the Intercalated Cells of Late Distal and
Collecting Tubules 392
Combination of Excess Hydrogen Ions
with Phosphate and Ammonia Buffers
in the Tubule—A Mechanism for
Generating “New” Bicarbonate Ions 392
Phosphate Buffer System Carries Excess
Hydrogen Ions into the Urine and
Generates New Bicarbonate 393
Excretion of Excess Hydrogen Ions and
Generation of New Bicarbonate by the
Ammonia Buffer System 393
Quantifying Renal Acid-Base Excretion 394
Regulation of Renal Tubular Hydrogen Ion
Secretion 395
Renal Correction of Acidosis—Increased
Excretion of Hydrogen Ions and
Addition of Bicarbonate Ions to the
Extracellular Fluid 396
Acidosis Decreases the Ratio of HCO3
-/H+ in
Renal Tubular Fluid 396
Renal Correction of Alkalosis—Decreased
Tubular Secretion of Hydrogen Ions
and Increased Excretion of
Bicarbonate Ions 396
Alkalosis Increases the Ratio of HCO3
-/H+
in Renal Tubular Fluid 396
Clinical Causes of Acid-Base Disorders 397
Respiratory Acidosis Is Caused by
Decreased Ventilation and Increased PCO2 397
Respiratory Alkalosis Results from Increased
Ventilation and Decreased PCO2 397
Metabolic Acidosis Results from Decreased
Extracellular Fluid Bicarbonate
Concentration 397
Treatment of Acidosis or Alkalosis 398
Clinical Measurements and Analysis of
Acid-Base Disorders 398
Complex Acid-Base Disorders and Use of
the Acid-Base Nomogram for Diagnosis 399
Use of Anion Gap to Diagnose Acid-Base
Disorders 400
C H A P T E R 3 1
Kidney Diseases and Diuretics 402
Diuretics and Their Mechanisms of
Action 402
Osmotic Diuretics Decrease Water
Reabsorption by Increasing Osmotic
Pressure of Tubular Fluid 402
“Loop” Diuretics Decrease Active
Sodium-Chloride-Potassium Reabsorption
in the Thick Ascending Loop of Henle 403
Thiazide Diuretics Inhibit Sodium-Chloride
Reabsorption in the Early Distal Tubule 404
Carbonic Anhydrase Inhibitors Block
Sodium-Bicarbonate Reabsorption in the
Proximal Tubules 404
Competitive Inhibitors of Aldosterone
Decrease Sodium Reabsorption from and
Potassium Secretion into the Cortical
Collecting Tubule 404
Diuretics That Block Sodium Channels
in the Collecting Tubules Decrease
Sodium Reabsorption 404
Kidney Diseases 404
Acute Renal Failure 404
Prerenal Acute Renal Failure Caused by
Decreased Blood Flow to the Kidney 405
Intrarenal Acute Renal Failure Caused by
Abnormalities within the Kidney 405
Postrenal Acute Renal Failure Caused by
Abnormalities of the Lower Urinary
Tract 406
Physiologic Effects of Acute Renal Failure 406
Chronic Renal Failure: An Irreversible
Decrease in the Number of Functional
Nephrons 406
Vicious Circle of Chronic Renal Failure
Leading to End-Stage Renal Disease 407
Injury to the Renal Vasculature as a Cause
of Chronic Renal Failure 408
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Injury to the Glomeruli as a Cause of
Chronic Renal Failure—
Glomerulonephritis 408
Injury to the Renal Interstitium as a
Cause of Chronic Renal Failure—
Pyelonephritis 409
Nephrotic Syndrome—Excretion of Protein
in the Urine Because of Increased
Glomerular Permeability 409
Nephron Function in Chronic Renal Failure 409
Effects of Renal Failure on the Body
Fluids—Uremia 411
Hypertension and Kidney Disease 412
Specific Tubular Disorders 413
Treatment of Renal Failure by Dialysis
with an Artificial Kidney 414
U N I T V I
Blood Cells, Immunity, and Blood
Clotting
C H A P T E R 3 2
Red Blood Cells, Anemia, and
Polycythemia 419
Red Blood Cells (Erythrocytes) 419
Production of Red Blood Cells 420
Formation of Hemoglobin 424
Iron Metabolism 425
Life Span and Destruction of Red Blood
Cells 426
Anemias 426
Effects of Anemia on Function of the
Circulatory System 427
Polycythemia 427
Effect of Polycythemia on Function of the
Circulatory System 428
C H A P T E R 3 3
Resistance of the Body to Infection: I.
Leukocytes, Granulocytes, the
Monocyte-Macrophage System, and
Inflammation 429
Leukocytes (White Blood Cells) 429
General Characteristics of Leukocytes 429
Genesis of the White Blood Cells 430
Life Span of the White Blood Cells 431
Neutrophils and Macrophages Defend
Against Infections 431
Phagocytosis 431
Monocyte-Macrophage Cell System
(Reticuloendothelial System) 432
Inflammation: Role of Neutrophils and
Macrophages 434
Inflammation 434
Macrophage and Neutrophil Responses
During Inflammation 434
Eosinophils 436
Basophils 436
Leukopenia 436
The Leukemias 437
Effects of Leukemia on the Body 437
C H A P T E R 3 4
Resistance of the Body to Infection: II.
Immunity and Allergy 439
Innate Immunity 439
Acquired (Adaptive) Immunity 439
Basic Types of Acquired Immunity 440
Both Types of Acquired Immunity Are
Initiated by Antigens 440
Lymphocytes Are Responsible for
Acquired Immunity 440
Preprocessing of the T and B Lymphocytes 440
T Lymphocytes and B-Lymphocyte
Antibodies React Highly Specifically
Against Specific Antigens—Role of
Lymphocyte Clones 442
Origin of the Many Clones of Lymphocytes 442
Specific Attributes of the B-Lymphocyte
System—Humoral Immunity and the
Antibodies 443
Special Attributes of the T-Lymphocyte
System–Activated T Cells and Cell-
Mediated Immunity 446
Several Types of T Cells and Their Different
Functions 446
Tolerance of the Acquired Immunity
System to One’s Own Tissues—Role
of Preprocessing in the Thymus and
Bone Marrow 448
Immunization by Injection of Antigens 448
Passive Immunity 449
Allergy and Hypersensitivity 449
Allergy Caused by Activated T Cells:
Delayed-Reaction Allergy 449
Allergies in the “Allergic” Person, Who Has
Excess IgE Antibodies 449
C H A P T E R 3 5
Blood Types; Transfusion; Tissue and
Organ Transplantation 451
Antigenicity Causes Immune Reactions
of Blood 451
O-A-B Blood Types 451
A and B Antigens—Agglutinogens 451
Agglutinins 452
Agglutination Process In Transfusion
Reactions 452
Blood Typing 453
Rh Blood Types 453
Rh Immune Response 453
Transfusion Reactions Resulting from
Mismatched Blood Types 454
Transplantation of Tissues and Organs 455
Attempts to Overcome Immune Reactions
in Transplanted Tissue 455
C H A P T E R 3 6
Hemostasis and Blood Coagulation 457
Events in Hemostasis 457
Vascular Constriction 457
Formation of the Platelet Plug 457
Blood Coagulation in the Ruptured
Vessel 458
Fibrous Organization or Dissolution of the
Blood Clot 458
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Table of Contents xxiii
Mechanism of Blood Coagulation 459
Conversion of Prothrombin to Thrombin 459
Conversion of Fibrinogen to Fibrin—
Formation of the Clot 460
Vicious Circle of Clot Formation 460
Initiation of Coagulation: Formation of
Prothrombin Activator 461
Prevention of Blood Clotting in the
Normal Vascular System—Intravascular
Anticoagulants 463
Lysis of Blood Clots—Plasmin 464
Conditions That Cause Excessive
Bleeding in Human Beings 464
Decreased Prothrombin, Factor VII,
Factor IX,and Factor X Caused by
Vitamin K Deficiency 464
Hemophilia 465
Thrombocytopenia 465
Thromboembolic Conditions in the
Human Being 465
Femoral Venous Thrombosis and Massive
Pulmonary Embolism 466
Disseminated Intravascular Coagulation 466
Anticoagulants for Clinical Use 466
Heparin as an Intravenous Anticoagulant 466
Coumarins as Anticoagulants 466
Prevention of Blood Coagulation Outside
the Body 466
Blood Coagulation Tests 467
Bleeding Time 467
Clotting Time 467
Prothrombin Time 467
U N I T V I I
Respiration
C H A P T E R 3 7
Pulmonary Ventilation 471
Mechanics of Pulmonary Ventilation 471
Muscles That Cause Lung Expansion and
Contraction 471
Movement of Air In and Out of the Lungs
and the Pressures That Cause the
Movement 472
Effect of the Thoracic Cage on Lung
Expansibility 474
Pulmonary Volumes and Capacities 475
Recording Changes in Pulmonary Volume—
Spirometry 475
Abbreviations and Symbols Used in
Pulmonary Function Tests 476
Determination of Functional Residual
Capacity, Residual Volume, and Total
Lung Capacity—Helium Dilution Method 476
Minute Respiratory Volume Equals
Respiratory Rate Times Tidal Volume 477
Alveolar Ventilation 477
“Dead Space” and Its Effect on Alveolar
Ventilation 477
Rate of Alveolar Ventilation 478
Functions of the Respiratory
Passageways 478
Trachea, Bronchi, and Bronchioles 478
Normal Respiratory Functions of the
Nose 480
C H A P T E R 3 8
Pulmonary Circulation, Pulmonary
Edema, Pleural Fluid 483
Physiologic Anatomy of the Pulmonary
Circulatory System 483
Pressures in the Pulmonary System 483
Blood Volume of the Lungs 484
Blood Flow Through the Lungs and
Its Distribution 485
Effect of Hydrostatic Pressure
Gradients in the Lungs on Regional
Pulmonary Blood Flow 485
Zones 1, 2, and 3 of Pulmonary Blood Flow 485
Effect of Increased Cardiac Output on
Pulmonary Blood Flow and Pulmonary
Arterial Pressure During Heavy Exercise 486
Function of the Pulmonary Circulation
When the Left Atrial Pressure Rises as a
Result of Left-Sided Heart Failure 487
Pulmonary Capillary Dynamics 487
Capillary Exchange of Fluid in the Lungs,
and Pulmonary Interstitial Fluid Dynamics 487
Pulmonary Edema 488
Fluid in the Pleural Cavity 489
C H A P T E R 3 9
Physical Principles of Gas Exchange;
Diffusion of Oxygen and Carbon
Dioxide Through the Respiratory
Membrane 491
Physics of Gas Diffusion and Gas
Partial Pressures 491
Molecular Basis of Gas Diffusion 491
Gas Pressures in a Mixture of Gases—
“Partial Pressures” of Individual Gases 491
Pressures of Gases Dissolved in Water
and Tissues 492
Vapor Pressure of Water 492
Diffusion of Gases Through Fluids—
Pressure Difference Causes Net
Diffusion 493
Diffusion of Gases Through Tissues 493
Composition of Alveolar Air—Its Relation
to Atmospheric Air 493
Rate at Which Alveolar Air Is Renewed by
Atmospheric Air 494
Oxygen Concentration and Partial Pressure
in the Alveoli 494
CO2 Concentration and Partial Pressure in
the Alveoli 495
Expired Air 495
Diffusion of Gases Through the
Respiratory Membrane 496
Factors That Affect the Rate of Gas
Diffusion Through the Respiratory
Membrane 498
Diffusing Capacity of the Respiratory
Membrane 498
Effect of the Ventilation-Perfusion
Ratio on Alveolar Gas Concentration 499
PO2-PCO2, V
.
A/Q
.
Diagram 500
Concept of the “Physiological Shunt”
(When V
.
A/Q
.
Is Greater Than Normal) 500
Abnormalities of Ventilation-Perfusion Ratio 501
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xxiv Table of Contents
C H A P T E R 4 0
Transport of Oxygen and Carbon
Dioxide in Blood and Tissue Fluids 502
Transport of Oxygen from the Lungs to
the Body Tissues 502
Diffusion of Oxygen from the Alveoli to the
Pulmonary Capillary Blood 502
Transport of Oxygen in the Arterial Blood 503
Diffusion of Oxygen from the Peripheral
Capillaries into the Tissue Fluid 503
Diffusion of Oxygen from the Peripheral
Capillaries to the Tissue Cells 504
Diffusion of Carbon Dioxide from the
Peripheral Tissue Cells into the
Capillaries and from the Pulmonary
Capillaries into the Alveoli 504
Role of Hemoglobin in Oxygen Transport 505
Reversible Combination of Oxygen with
Hemoglobin 505
Effect of Hemoglobin to “Buffer” the
Tissue PO2 507
Factors That Shift the Oxygen-Hemoglobin
Dissociation Curve—Their Importance for
Oxygen Transport 507
Metabolic Use of Oxygen by the Cells 508
Transport of Oxygen in the Dissolved State 509
Combination of Hemoglobin with Carbon
Monoxide—Displacement of Oxygen 509
Transport of Carbon Dioxide in the Blood 510
Chemical Forms in Which Carbon Dioxide
Is Transported 510
Carbon Dioxide Dissociation Curve 511
When Oxygen Binds with Hemoglobin,
Carbon Dioxide Is Released (the Haldane
Effect) to Increase CO2 Transport 511
Change in Blood Acidity During Carbon
Dioxide Transport 512
Respiratory Exchange Ratio 512
C H A P T E R 4 1
Regulation of Respiration 514
Respiratory Center 514
Dorsal Respiratory Group of Neurons—Its
Control of Inspiration and of Respiratory
Rhythm 514
A Pneumotaxic Center Limits the Duration
of Inspiration and Increases the
Respiratory Rate 514
Ventral Respiratory Group of Neurons—
Functions in Both Inspiration and
Expiration 515
Lung Inflation Signals Limit Inspiration—
The Hering-Breuer Inflation Reflex 515
Control of Overall Respiratory Center
Activity 516
Chemical Control of Respiration 516
Direct Chemical Control of Respiratory
Center Activity by Carbon Dioxide and
Hydrogen Ions 516
Peripheral Chemoreceptor System for
Control of Respiratory Activity—Role
of Oxygen in Respiratory Control 518
Effect of Low Arterial PO2 to Stimulate
Alveolar Ventilation When Arterial Carbon
Dioxide and Hydrogen Ion Concentrations
Remain Normal 519
Chronic Breathing of Low Oxygen Stimulates
Respiration Even More—The Phenomenon
of “Acclimatization” 519
Composite Effects of PCO2, pH, and PO2 on
Alveolar Ventilation 519
Regulation of Respiration During
Exercise 520
Other Factors That Affect Respiration 521
Sleep Apnea 522
C H A P T E R 4 2
Respiratory Insufficiency—
Pathophysiology, Diagnosis, Oxygen
Therapy 524
Useful Methods for Studying Respiratory
Abnormalities 524
Study of Blood Gases and Blood pH 524
Measurement of Maximum Expiratory Flow 525
Forced Expiratory Vital Capacity and Forced
Expiratory Volume 526
Physiologic Peculiarities of Specific
Pulmonary Abnormalities 526
Chronic Pulmonary Emphysema 526
Pneumonia 527
Atelectasis 528
Asthma 529
Tuberculosis 530
Hypoxia and Oxygen Therapy 530
Oxygen Therapy in Different Types of
Hypoxia 530
Cyanosis 531
Hypercapnia 531
Dyspnea 532
Artificial Respiration 532
U N I T V I I I
Aviation, Space, and Deep-Sea
Diving Physiology
C H A P T E R 4 3
Aviation, High-Altitude, and Space
Physiology 537
Effects of Low Oxygen Pressure on the
Body 537
Alveolar PO2 at Different Elevations 537
Effect of Breathing Pure Oxygen on Alveolar
PO2 at Different Altitudes 538
Acute Effects of Hypoxia 538
Acclimatization to Low PO2 539
Natural Acclimatization of Native Human
Beings Living at High Altitudes 540
Reduced Work Capacity at High Altitudes
and Positive Effect of Acclimatization 540
Acute Mountain Sickness and High-Altitude
Pulmonary Edema 540
Chronic Mountain Sickness 541
Effects of Acceleratory Forces on the
Body in Aviation and Space Physiology 541
Centrifugal Acceleratory Forces 541
Effects of Linear Acceleratory Forces on the
Body 542
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Table of Contents xxv
“Artificial Climate” in the Sealed
Spacecraft 543
Weightlessness in Space 543
C H A P T E R 4 4
Physiology of Deep-Sea Diving and
Other Hyperbaric Conditions 545
Effect of High Partial Pressures of
Individual Gases on the Body 545
Nitrogen Narcosis at High Nitrogen
Pressures 545
Oxygen Toxicity at High Pressures 546
Carbon Dioxide Toxicity at Great Depths
in the Sea 547
Decompression of the Diver After Excess
Exposure to High Pressure 547
Scuba (Self-Contained Underwater
Breathing Apparatus) Diving 549
Special Physiologic Problems in
Submarines 550
Hyperbaric Oxygen Therapy 550
U N I T I X
The Nervous System: A. General
Principles and Sensory Physiology
C H A P T E R 4 5
Organization of the Nervous System,
Basic Functions of Synapses,
“Transmitter Substances” 555
General Design of the Nervous System 555
Central Nervous System Neuron: The Basic
Functional
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